Transcatheter Splenic Artery Occlusion for Treatment of Splenic Artery Steal Syndrome After Orthotopic Liver Transplantation

Purpose: To review some aspects of the problem of splenic artery steal syndrome as cause of ischemia in transplanted livers and treatment by selective splenic artery occlusion. Materials and Methods: Eleven liver transplant patients from a group of 350 patients, nine men and two women, ranging in age from 40 years to 61 years (mean 52 years), presented with biochemical evidences of liver ischemia and failure, ranging from one to 60 days following orthotopic liver transplantation. Diagnosis of splenic artery steal syndrome was suspected by elevated enzymes, Doppler ultrasound and confirmed by celiac angiogram. Patients with confirmed hepatic artery thrombosis before angiography were excluded from the study. Embolization with Gianturco coils was performed. Results: All patients were treated by splenic artery embolization with Gianturco coils. The 11 patients improved clinically within 24 hours of the procedure with significant change in the biochemical and clinical parameters. Followup ranged from one month to two years. One of the 11 patient initially improved, but developed hepatic artery thrombosis within 24 hours of the embolic treatment, requiring surgical repair. Conclusion: Splenic artery steal syndrome following liver transplantation surgery can be diagnosed by celiac angiography, and effectively treated by splenic artery embolization with coils. Embolization is one of the treatments available, it is minimally invasive, and leads to immediate clinical improvement. Hepatic artery thrombosis is a possible complication of the procedure.     

Thrombosed dialysis access grafts: randomized comparison of the Amplatz thrombectomy device and surgical thromboembolectomy

We report the final results of the trial comparing the Amplatz thrombectomy device (ATD) with surgical thromboembolectomy (ST) to declot thrombosed dialysis access grafts (DAG). The study population consisted of 174 DAG, 109 of which were randomized to mechanical thrombectomy using the ATD and 65 of which were randomized to conventional surgical thromboembolectomy. Forty grafts were re-enrolled in the trial when they failed beyond the 90 days follow-up after the initial treatment. Thirty-one were re-enrolled for mechanical thrombectomy and nine were re-enrolled for surgical thrombectomy, resulting in a total of 140 ATD procedures and 74 surgical thromboembolectomy. Immediate thrombectomy success was defined as greater than 90% thrombus removal followed by the ability to dialyze after treatment, and analysis of long term success based on graft patency at 30 and 90 days, with successful dialysis. Immediate thrombectomy success with the ATD procedure was achieved in 79.2% and with ST in 73.4%. Patency of the graft, with successful dialysis, at 30 days with the ATD procedure was 79.2% and with ST was 73.4%. Patency of the graft, with successful dialysis, at 90 days with the ATD procedure was 75.2% and with ST was 67.8%. The data collected in this study provided a prospective comparison of mechanical thrombectomy with the ATD and ST performance in thrombosed DAG. The results of the performance of both methods were comparable. No statistically significant differences were seen.List of Investigators: Carol C. Steenson (Department of Radiology, VA Medical Center, Minneapolis, MN), Renan Uflacker (Interventional Radiology, Medical University of South Carolina, Charleston, SC), Richard J. Gray (Interventional Radiology, Washington Hospital Center, Washington, DC), George A. Fueredi (St Marys Hospital, Milwaukee, WI), Michael P. Hickman (Vascular and Interventional Radiology, St Josephs Regional Health Center, Hot Springs, AR), Robert Smith (Interventional Radiology, Tulane University Medical Center, New Orleans, LA), Paul Kamin (Department of Radiology, Los Alamitos Medical Center, Los Alamitos, CA), Mac Dryjski (Department of Surgery, Millard Filmore Hospital, Buffalo, NY), Michael Bettman (Vascular and Interventional Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH).     

Gastrointestinal involvement in neurofibromatosis: Angiographic presentation

A large neurofibroma associated with gastrointestinal hemorrhage was demonstrated by visceral arteriography. The findings are correlated with those of resected pathologic specimen.     

Successful embolization of a bleeding splenic artery pseudoaneurysm secondary to necrotizing pancreatitis

A case of successful obliteration of a bleeding splenic artery pseudoaneurysm secondary to necrotizing pancreatitis is reported. The material used for embolization was stainless steel coils. A variation of the technique is introduced. Instead of occluding the pseudoaneurysm cavity itself, embolization only of the afferent vessel is advised.     

Association of congenital cystic dilatation of the common bile duct and congenital diverticulum of the hepatic duct with concomitant ascariasis.

A case with association of congenital cystic dilatation of the common bile duct and congenital diverticulum of the hepatic duct is reported. The etiology and classification are briefly discussed and a radiological approach is recommended.     

Percutaneous transhepatic biliary drainage: alternatives in left hepatic duct obstruction

The left-lobe subxiphoid approach has been the standard way to drain left hepatic duct occlusion. A new, right-side biliary drainage approach is described. Five patients, among 25 patients with bilateral biliary obstruction, were treated by an internal-internal drainage system. Three types of internal-internal drainage techniques are described: internal-internal luminal, type 1; internal-internal luminal, type 2; and internal-internal transductal, type 3. All 5 patients succeeded in biliary drainage. The internal-internal biliary drainage technique, performed from the right-side approach, is effective, avoids additional liver puncture and tract dilatation, and allows the combination of several biliary drainage techniques, adding greatly to the flexibility when treating intrahepatic obstruction. No complications were observed in our small series but special precaution should be taken with the transductal technique due to the possibility of bleeding.     

Association of congenital cystic dilatation of the common bile duct and congenital diverticulum of the hepatic duct with concomitant ascariasis

A case with association of congenital cystic dilatation of the common bile duct and congenital diverticulum of the hepatic duct is reported. The etiology and classification are briefly discussed and a radiological approach is recommended.     

Filling of the aneurysmal sac with DEAC-glucosamine in an animal model of abdominal aortic aneurysm following stent-graft repair

AIM: The aim of this study was to present the preliminary results of a technique of abdominal aortic aneurysm (AAA) sac filling in an attempt to obliterate the sac in a swine AAA model, using deacetylated-poly-N-acetyl glucosamine (DEAC-poly-N-acetyl glucosamine). METHODS: Eleven Yucatan pigs, 6 months of age, 40 kg -60 kg, were used to create an AAA with a Dacron pouch implanted surgically and left to mature for 2 weeks. One animal was used to establish the AAA creation procedures. Eight animals were used for AAA sac filling; of the 8 subjects 2 were used for acute studies, and 6 for longer-term studies. Two additional animals were used as controls without polymer sac filling. Two weeks after the AAA creation, a 13 mmx5.5 cm straight tube AneuRx stent-graft was placed to exclude the aneurysm. The aneurysmal sac was filled with a polymer, DEAC-poly-N-acetyl glucosamine at 1.5%, 70% deacetylated, mixed with iohexol. There was filling of a lumbar artery by the polymer in 2 animals. Endpoints were at 1, 2, 4, 6, 12 and 24 weeks, in the chronic study animals and 6 and 12 weeks in the control subjects, procedures consisting of aortography followed by necropsy and pathologic examination. RESULTS: The AAA creation and aneurysm sac filling was successful in all animals. An organized thrombus layer of about 2 mm in thickness was observed in all subjects along the Dacron aneurysm wall. All aneurysms were angiographically patent at the time of treatment, but fresher thrombus within the sac was seen in 4 subjects before the polymer injection. The stent-graft placement excluded the AAA sac and the polymer injection filled all AAA sacs. The AAA sac had acquired a firm rubbery consistency at the time of necropsy. There was mild inflammatory reaction to the Dacron material in the surrounding tissues and within the sac, to a lesser extent. Two animals developed paralysis of the hind limbs following treatment, most likely related to spinal ischemia, and were used as acute subjects. There was no recanalization of the aneurysm sac, during the follow-up time, ranging from 1 to 24 weeks in the treatment or control subjects. There was a 25% shrinkage of the AAA sac at 6th, 40% at 12th week and 75% by the 24th week. The 2 control subjects showed shrinkage of less than 25% at 6 and 12 weeks. There was replacement of the polymer/thrombus complex by connective tissue, fat tissue with capillary neovascularization in the treated subjects. Fibrosis and calcifications were also detected within the sac, mostly around the stent-graft and in contact with the aortic wall starting at 4 weeks. Control subjects did not show replacement of the thrombus by connective tissue or neovascularization. CONCLUSION: The results of this preliminary study support the aneurysm sac filling as a potential tool to exclude the aneurismal sac, promoting shrinkage of the AAA. DEAC -poly-N-acetyl glucosamine promotes clotting within the AAA sac with progressive replacement by connective tissue and neovascularization and may have a potential to prevent endoleaks. The polymer is easy to use, and it seems to have adequate gradual long-term replacement properties, preventing aneurysm sac recanalization.